News to Note – August 2020

• Similar to Healthgrades and Leapfrog which rate hospitals and let hospitals then pay them huge sums of money to advertise how well they did, (for example, in 2019 a hospital with over 400 beds had to pay Leapfrog $19,900 to advertise their safety rating), there is another non-profit organization joining the mix, called the Lown Institute. They describe themselves as, “a non-partisan think tank advocating bold ideas for a just and caring system for health.” They actually give awards every year to the top examples of greed and dysfunction in health care, with recent winners including the hospital that kept a vegetative transplant patient alive for seven months so his death would not adversely affect their transplant survival rate, and the head of a famous cancer hospital who forgot to tell his employers about the millions of dollars he was being paid by pharmaceutical companies which created a huge conflict of interest. Now, they have developed their own hospital rating system that uses the usual measures like patient safety and patient satisfaction but also factors into their rating scores for civic leadership – measured by pay equity, community benefit and inclusivity – and the value of the care provided – measured by the avoidance of tests and treatments that have been proven to offer little or no clinical benefit. You read that right, they measure value based on what the hospital does not do rather than what it does do. What kinds of things do they consider unnecessary? It probably won’t surprise you that tests ordered for patients with syncope top the list, including EEG, brain imaging, and carotid artery ultrasound. Vertebroplasty, Swan-Ganz catheters, and renal artery stenting are also on the list. But unlike the others, Lown does not charge hospitals for the privilege of advertising their scores. Google “Lown institute” and see how your hospital did.
• The PEPPER, the report produced by one of many CMS contractors that compares hospitals on measures that CMS considers error-prone. The contractor that produces the PEPPER also produces comparative billing reports. A comparative billing report also looks at high risk areas but it is more specific. For instance, a report for dermatologists looking at Mohs surgery, or for gastroenterologists performing upper and lower endoscopy on different days. The latest report looks at the rate of patients having joint replacement without having conservative care, beforehand. How do they do that? They decided to look at two things – billing of any physical or occupational therapy services at any point in the previous 12 months, or billing for any joint injection in the previous 12 months. Clearly, this is not perfect and will miss some cases, but everyone is subjected to the same standard. Every physician who performed at least ten surgeries will get a report that gives them their raw rate and compares them to their colleagues at the state and national level. Only the physician gets this report so there is no opportunity for public shaming. But, we do have national data available to us, and it’s pitiful. Over 51% of patients had joint replacement surgery without having any conservative therapy in 2019. The worst state is Vermont at 71% and the best, if you can call it that, is Illinois at 40%. What can we do with this information? We suspect the RACs are salivating, knowing that they can deny 50% of charts they audit if CMS gives them the green light. You may want to consider an internal audit to see how your charts look.
• Keeping on the topic of comparative billing reports, another was recently released looking at patients who had intervention for peripheral vascular disease – such as stenting – without first undergoing structured exercise therapy. What is structured exercise therapy? It’s like cardiac rehab. The patient goes to a hospital-based clinic and gets exercise with close monitoring and education. It is recommended by guidelines that patients undergo structured exercise therapy prior to intervention. You may recall that for joint replacement, 50% of patients had no conservative therapy and that seemed terrible. For peripheral vascular intervention, 86% of patients nationally did not have prior structured exercise therapy. Only 14% had it. That sounds horrendous but only 11% of hospitals nationally even offer exercise therapy. So, if 14% of patients get exercise therapy, maybe that’s not so bad. What is the value in this report? All it does is tell doctors they should be ordering a treatment for their patients that is not available for them to order. Not so helpful…
• You no doubt fear the notice you get that the Joint Commission surveyors have arrived in the building. If a planned survey, it was preceded by weeks of preparation. If an unplanned visit, then it is absolute mayhem as everyone runs around checking cabinets and buffing up charts. These surveys are supposed to be done by CMS themselves, but they deemed some other organizations can do the surveys just well. The Joint Commission just had their status renewed, but only for two years. Why? Because CMS has concerns about certain areas where they feel the Joint Commission did not meet their standards. The normal approval is for six years. What does this mean? If you thought they were arbitrary and picky before, now with the heat on them, they are going to double down on pickiness. You might want to talk to your compliance and leadership team to be sure they know it may get ugly.
• CMS audits have re-started, and claims submitted during the pandemic are sure to be an auditor’s paradise. But, many of those errors could have been prevented if CMS simply issued clear instructions with common examples. If you listen to the CMS Tuesday calls, you know that every week there are at least three or four questions about the difference between Q3014 and G0463 and the proper application of the CS modifier. We are four months into this and if there is still that much confusion, it is not the fault of providers. Also, CMS is deferring many issues back to the MACs. But, at the same time, CMS has been hearing from multiple callers that the MACs are giving out blatantly wrong information. A few weeks ago, NGS admitted that it was improperly denying claims for COVID testing. Not very encouraging when you do everything right and your claim still gets denied. It also does not help that every insurance company thinks they know best by establishing their own coding and coverage rules. Wouldn’t it be nice if the same set of rules applied to every patient?
• The public health emergency was extended again – and it was announced on Twitter before it was announced on any government web site. More proof that Twitter is a good resource to keep up to date! And, when you create your account, be sure to follow us at @AmerCollPhyAdv. This extension means that all of the waivers remain in place for now, including the SNF three-day waiver. Although, sadly, the SNFs can still refuse patients without a three day stay for any reason they want.